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Adverse Effects of Mouth Breathing AGD - Academy of General Denstry hp://www.agd.org/publicaons/arcles/?ArtID=6850 Mouth breathing: Adverse effects on facial growth, health, Contact Us academics, and behavior Send to a Friend By Yosh Jefferson, DMD, MAGD Send to Printer Featured in General Dentistry , January/February 2010 Pg. 18-25 Close Window Posted on Friday, January 08, 2010 The vast majority of health care professionals are unaware of the negative impact of upper airway obstruction (mouth breathing) on normal facial growth and physiologic health. Children whose mouth breathing is untreated may develop long, narrow faces, narrow mouths, high palatal vaults, dental malocclusion, gummy smiles, and many other unattractive facial features, such as skeletal Class II or Class III facial profiles. These children do not sleep well at night due to obstructed airways; this lack of sleep can adversely affect their growth and academic performance. Many of these children are misdiagnosed with attention deficit disorder (ADD) and hyperactivity. It is important for the entire health care community (including general and pediatric dentists) to screen and diagnose for mouth breathing in adults and in children as young as 5 years of age. If mouth breathing is treated early, its negative effect on facial and dental development and the medical and social problems associated with it can be reduced or averted. Received: February 11, 2009 Accepted: May 5, 2009 The importance of facial appearances in contemporary society is undeniable. Many studies have shown that individuals with attractive facial features are more readily accepted than those with unattractive facial features, providing them with significant advantages. 1-6 However, many health care professionals (as well as the public) feel that individual facial features are the result of genetics and therefore cannot be altered or changed—in other words, the genotype ultimately controls the phenotype. However, more and more studies are showing that environmental factors may play a significant role in facial and dental development and may alter the phenotype. In the most definitive experiments to study the relationship between airway obstruction and craniofacial growth, latex plugs were inserted in the nasal openings of young rhesus monkeys. The sudden change from nasal respiration to oral respiration caused changes in the function of the masticatory muscles. 7 The first noticeable changes were functional, as the animals altered their neuromuscular pattern of activity to breathe. With their nasal respiration blocked, individual monkeys achieved respiration in different ways; some postured their mandible with a downward and backward (retrusive) opening rotation, while others lowered and raised their mandibles rhythmically with each breath. Still others postured their jaws in a downward and forward (protrusive) position. Each in its own way was able to respirate; however, all did so via mouth breathing. 7 Harvold reported that the distance from the nasion to the chin increased significantly in mouth breathing animals; in addition, the distance from the nasion to the hard palate increased, due to the downward displacement of the maxilla. The lower border of the mandible became steeper and the gonial angle increased. It is significant that these animals developed long faces. 7 A change in breathing pattern led to a variety of skeletal and dental deformities in an animal that ordinarily does not develop malocclusions and facial abnormalities under natural conditions. It was not the change in breathing pattern that caused the malocclusion and the various forms of facial disharmony; rather, the ultimate facial and dental abnormalities depended on which of the three forms of respiration the animal developed. Animals that rhythmically lowered and raised their mandibles with each breath developed a Class I open bite and a skeletal Class I open bite (that is, long faces). Animals that rotated their mandibles in a posterior and inferior direction developed a Class II malocclusion and a skeletal Class II profile. The animals whose mandible maintained an anterior position developed a Class III malocclusion and a skeletal Class III profile. 7 The literature has shown a correlation between mouth breathing and abnormal facial growth in humans. McNamara found a relationship between upper airway obstruction and deviant facial growth. 8 Bresolin et al studied 45 North 1 of 13 1/11/2011 9:26 PM AGD - Academy of General Denstry hp://www.agd.org/publicaons/arcles/?ArtID=6850 American Caucasians (30 chronic mouth breathers and 15 nasal breathers) of both sexes (ranging in age from 6–12 years) and found that mouth breathers had longer faces with a narrower maxilla and retrognathic jaws. 9,10 Trask et al studied 64 children medically, dentally, and cephalometrically: 25 allergic children who were mouth breathers, 25 nasal breathing siblings, and 14 nasal breathing control subjects. The authors found that the allergic children had longer and more retrusive faces than the control group. 11 The patient in Figure 1 illustrates how untreated mouth breathing in children can cause abnormal myofunction. Left untreated, this condition can adversely affect normal facial growth and dental development. At age 6, the child had normal facial features; however, her mouth breathing went untreated. By age 9, the child had developed a long, narrow face and severe dental malocclusion. She was successfully treated using functional appliance therapy. Mouth breathing and its negative impact on health In addition to various types of abnormal facial growth and dental malocclusions, many other medical problems can be attributed to mouth breathing. First and foremost, nasal respiration (which is produced in the nasal sinuses) is essential for the production of nitric oxide. 12-14 Nitric oxide inhaled via nasal respiration has been shown to increase oxygen exchange efficiency and increase blood oxygen by 18%, while improving the lungs’ ability to absorb oxygen. 15,16 Nitric oxide also is a strong vasodilator and brain transmitter that increases oxygen transport throughout the body and is vital to all body organs. 17 Nitric oxide is crucial to overall health and the efficiency of smooth muscles, such as blood vessels and the heart. 18-25 Many other health benefits have been attributed to nitric oxide. 26-28 Nasal respiration provides the most efficient mechanism for introducing oxygen into the lungs and body for overall health. Mouth breathers have a lower oxygen concentration in their blood than those who have optimal nasal respiration; low oxygen concentration in the blood has been associated with high blood pressure and cardiac failures. 29-32 The negative impact of sleeping disorders on growth and development has been substantiated in many studies. Many children with sleep disorders are often well below their peers in terms of height and weight. 33-38 Other major issues beyond abnormal facial and dental development also have been associated with mouth breathing. Studies have shown that upper airway obstruction/mouth breathing can cause sleep disorders and sleep apnea. 39-44 Studies have shown that children with sleep disorders have problems paying attention in school, are often tired, and 2 of 13 1/11/2011 9:26 PM AGD - Academy of General Denstry hp://www.agd.org/publicaons/arcles/?ArtID=6850 may exhibit behavior problems; many of these children often are misdiagnosed with attention deficit hyperactivity disorder (ADHD). 45-50 The current standard of care for children, adolescents, and adults with ADHD is medication with such stimulant drugs as Adderall (Shire US Inc.) or Ritalin (Novartis Pharmaceuticals). 51-53 These medications have raised concerns about reduced height and weight, cardiovascular effects, tics, evidence of carcinogenic and reproductive effects, and substance abuse. 54-61 ADHD is the most commonly diagnosed behavioral disorder in children; however, many of these children have sleep disorders and are being misdiagnosed. 62 In the author’s opinion, the ideal treatment for these children involves treating the blocked airway, allowing the child to breathe through the nose rather than the mouth. Mouth breathing irritates the mucosa, and these children often will have swollen tonsils and adenoids, one of the major causes of upper airway obstruction, sleep disorders, and sleep apnea. 63,64 Surgical removal of swollen tonsils and adenoids is highly recommended when they negatively affect sleep. 65-68 With surgical removal of swollen tonsils and adenoids, many of these children who were misdiagnosed with ADHD have shown marked improvement in behavior, attentiveness, energy level, academic performance, and growth and development; in addition, nocturnal enuresis was corrected. 69-75 The dentist’s role in the diagnosis and treatment of mouth breathing General and pediatric dentists may be in the best position to screen and treat patients who suffer from upper airway obstruction/mouth breathing. Dentists usually see patients on a regular basis every six months, and swollen tonsils can be easily detected by using a mouth mirror to look at the back of the patient’s throat. All patients—children, adolescents, and adults—should be screened for upper airway obstruction. All patients who have some or all of the conditions listed in the table (Fig. 2–5) should be examined for sleep disorders or sleep apnea. 3 of 13 1/11/2011 9:26 PM AGD - Academy of General Denstry hp://www.agd.org/publicaons/arcles/?ArtID=6850 4 of 13 1/11/2011 9:26 PM AGD - Academy of General Denstry
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